Many have hoped that what has commonly become known as “Obama Care” would simply go away! The reality is that the Affordable Care Act is law and it will
affect all of us. Idaho chose to create a state based exchange (Marketplace) rather than use the federal one.
What do I need to know and what do I need to do?
FAQ’s on Health Care Reform
- How does my broker help me?
- What do I need to do?
- What are Insurance Exchanges? aka Marketplace
- How do subsidies work?
- What is the difference between public and private exchanges?
- Can I get free Health Insurance?
- Do I have to buy health insurance through the Exchange?
- What happens if I chose not to buy health insurance?
- What is open enrollment?
- Can I keep my current plan, or will I be forced to buy a new plan?
- What is the SHOP exchange?
- What are navigators, certified application counselors, and assisters?
- Will health insurance cost more in 2014?
- How do lower out of pocket cost work and am I eligible?
- What are the metal plans?
- What are Essential Health Benefits?
How does my broker help me?
All agents, brokers and staff have worked diligently to understand how the new health care laws will impact you. We are prepared and ready to answer any questions
that you may have and to provide guidance as you need to make important decisions about your health coverage.
What do I need to do?
- Use our link(array(‘contact’,’index’));?>”>contact us at anytime.
- Unless you are in a grandfathered plan, be prepared to make a plan change, no later than your 2014 renewal.
What are Insurance Exchanges? aka Marketplace
An exchange is a public marketplace that allows you to compare insurance products, their pricing and plan details from multiple insurance carriers in one place. Exchanges also
provide enrollment options and subsidy verification.
How do subsidies work?
If your household income is between 100% and 400% of the federal poverty level, you likely qualify for a subsidy to help offset the cost of buying an individual health insurance
The subsidy is paid by the federal government directly to the insurance carrier. The premium you pay each month to the insurance carrier is the subsidized premium. You do NOT
need to pay the full premium and be reimbursed later.
If your personal or family income falls below 100% of the federal poverty level you may be eligible for Medicaid.
The amount you save depends on your family size and how much money your family earns. In general, people at the following income levels will qualify to save in 2014. The lower
your income, the higher your savings will be. (The amounts below are based on 2013 numbers and are likely to be slightly higher in 2014.)
- Up to $45,960 for individuals
- Up to $62,040 for a family of 2
- Up to $78,120 for a family of 3
- Up to $94,200 for a family of 4
- Up to $110,280 for a family of 5
- Up to $126,360 for a family of 6
- Up to $142,440 for a family of 7
- Up to $158,520 for a family of 8
You may also be able to get lower out-of-pocket cost depending on your income and family size.
When you apply for lower costs, you’ll need to estimate your household income for 2014.
For most people, you can use your household’s adjusted gross income for this estimate. If you know your 2013 adjusted gross income, use that and take into account any changes
you expect in 2014. When you fill out the Marketplace application, a number called “modified adjusted gross income” (MAGI) will be used.
Modified adjusted gross income is generally your household’s adjusted gross income plus any tax-exempt Social Security, interest, and foreign income you have. It’s used to
determine your eligibility for lower costs on Marketplace coverage and for Medicaid and the Children’s Health Insurance Program (CHIP).
So what happens if you get a subsidy payment in advance and then your spouse suddenly finds a job, boosting your family’s income? You’ll need to go through a reconciliation
process and pay back some of the subsidy. However, most households will need to repay only a portion of the overestimated subsidy. The amount you have to pay back will be based
on how much you earn.
Qualifying for Subsidies
If your employer offers health insurance that meets minimal value you will not qualify for a subsidy no matter what your income level. Your employer can tell you whether or
not the plan they offer meets the minimal value standard.
What is the difference between public and private exchanges?
Private exchanges generally offer greater flexibility than the public exchanges. Private exchange websites are required by law to follow specific guidelines when it comes to
showing exchange plans. The advantages that our private exchange website offers include:
- Compares exchange and private carriers plans side by side
- Shows all exchange plans
- Allows you to see the ‘raw’ unsubsidized rates, as well as to see the estimated rates you will pay using our subsidy calculator
- No financial questionnaire required to see plan details and rates
- Many tools to help you compare plans based upon filters that you apply based upon your personal needs
All of these services are provided at no cost to you! There is no cost for you to use any portion of our private exchange website; it is simply a service that we pass along to
our clients to help you evaluate your insurance needs.
Can I get free Health Insurance?
There are a lot of myths in regards to the new health care laws and plans that are offered, the simple answer is no. However you may qualify for a subsidy to assist you with
the cost of health insurance premiums. There are several factors which determine the amount of the subsidy you qualify for including your income, age and family size. Some
subsidized premiums may be close to $0.
Do I have to buy health insurance through the Exchange?
No. However the only way to qualify for the subsidy is if you purchase insurance through the exchange. Using our private exchange service allows you
‘compare’ plans and rates including subsidies side by side; before going to the state/federal exchange to complete your purchase.
What happens if I chose not to buy health insurance?
Beginning January 1, 2014, the Affordable Care Act will require most Americans, with few exceptions, to have health insurance. To aid in this process, the law mandates that
all health plans must guarantee policies to any individual or employer applicant regardless of health status. This includes those with preexisting medical conditions. Individuals
who are not covered by an insurance policy will be charged an annual penalty in the first year of $95, or up to 1 percent of annual income, whichever is greater. This penalty will
rise to a minimum of $695 ($2,085 for families) or 2.5 percent of income by 2016.
What is open enrollment?
Open enrollment is a specified timeframe in which you can not only buy health insurance products, but you can apply for a subsidy. Some insurance carriers will allow you to
buy health insurance outside of open enrollment, but you will not qualify for a subsidy unless you meet ‘special enrollment’ guidelines such as, your current plan is expiring and
will not continue (2014 only), loss of group coverage, marriage, divorce, newborn child and adoption. Specific open enrollment periods are as follows:
- Initial open-enrollment period — October 1, 2013, through March 31, 2014.
- Annual enrollment period — for benefit years starting on or after January 1, 2015 will be October 15 through December 7 of the preceding year.
Can I keep my current plan, or will I be forced to buy a new plan?
For most people, the answer is that we will have to buy a new metal plan through the Idaho Exchange. When your plan renews in 2014 you will need to move to a new exchange plan, unless your current plan is in a grandfathered status. Grandfathered plans are rare, so most people will need to move to a new plan.
What is the SHOP exchange?
It is the health insurance exchange for small employers (Small Business Health Options Program).
What are navigators, certified application counselors, and assisters?
These are individuals that are intended to provide assistance to individuals applying for medical assistance and/or enrolling on the exchange. They will primarily be regulated
by the Idaho exchange. They are NOT licensed brokers and they cannot make product recommendations.
Will health insurance cost more in 2014?
In general yes, however the premiums you personally pay, may be more or less, as there are a number of factors including; subsidy eligibility, plan selection, etc. that will
greatly affect the amount of premium you pay. Because all new plans must adhere to new lower out-of-pocket limits and essential health benefit guidelines, the overall affect is
How do lower out of pocket cost work and am I eligible?
When you get coverage through the exchange, you may be able to get lower costs on deductibles, copayments and coinsurance. This will depend on your income.
Cost-sharing reduction lowers the amount you have to pay for out-of-pocket costs like deductibles, coinsurance and copayments. These are costs you have to pay when you get care.
This savings is based on your income and family size.
Health insurance companies offering coverage through the Marketplace must lower the amount you pay out of pocket for essential health benefits if your household income is below
the following amounts. (Incomes below are based on 2013 numbers. They are likely to be slightly higher in 2014. Amounts are different for each family size, up to 8.)
- Up to $28,725 for individuals
- Up to $38,775 for a family of 2
- Up to $48,825 for a family of 3
- Up to $58,875 for a family of 4
- Up to $68,925 for a family of 5
- Up to $78,975 for a family of 6
- Up to $89,025 for a family of 7
- Up to $99,075 for a family of 8
When you apply for coverage in the Marketplace, you’ll learn if you’re eligible for these savings on out-of-pocket costs. If you qualify for out-of-pocket savings, you must choose a Silver plan to get the savings.
What are the metal plans?
All marketplace plans are separated into 4 different categories: Bronze, Silver, Gold, and Platinum. Platinum plans are the richest in benefits; Gold plans are the second
richest and so on. The metal designation is used to help when comparing plans. As a general guideline Platinum plans cover 90% of medical cost, Gold plans 80%, Silver plans
70% and Bronze 60%. Bronze plans are designed with the lowest monthly premium and highest cost sharing—such as deductibles, coinsurance and or copayments—when health care services
are utilized. Platinum plans generally have the highest monthly premium and lower cost sharing responsibility for the patient.
What are Essential Health Benefits?
Health plans offered both inside and outside of the Health Insurance Marketplace, offer a comprehensive package of items and services, known as essential health benefits.
Essential health benefits must include items and services within at least the following 10 categories: ambulatory patient services; emergency services; hospitalization; maternity
and newborn care; mental health and substance use disorder services, including behavioral health treatment; prescription drugs; rehabilitative and habilitative services and
devices; laboratory services; preventive and wellness services; chronic disease management; and pediatric services, including oral and vision care.
Insurance policies must cover these benefits in order to be certified and offered in the Health Insurance Marketplace.
Evaluate New Marketplace Options
The following steps can serve as a guide assisting you in your health care decisions and enrollment process beginning October 1st.